Radiographic enhancement of the nasoseptal flap does not predict postoperative cerebrospinal fluid leaks in endoscopic skull base reconstruction

Authors

  • Nithin D. Adappa MD,

    Corresponding author
    1. the Department of Otorhinolaryngology–Head and Neck Surgery , Hospital of the University of Pennsylvania
    • Department of Otorhinolaryngology–Head and Neck Surgery, Hospital of the University of Pennsylvania, Ravdin Building, 5th Floor, 3400 Spruce Street, Philadelphia, PA 19104
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  • Kim O. Learned MD,

    1. Department of Radiology–Neuroradiology Division , University of Pennsylvania Health System
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  • James N. Palmer MD,

    1. the Department of Otorhinolaryngology–Head and Neck Surgery , Hospital of the University of Pennsylvania
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  • Jason G. Newman MD,

    1. the Department of Otorhinolaryngology–Head and Neck Surgery , Hospital of the University of Pennsylvania
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  • John Y. K. Lee MD

    1. Department of Neurological Surgery , Pennsylvania Hospital, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A.
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  • Jason G. Newman, MD, is a consultant for Intuitive Surgical; John Y. K. Lee, MD, is a speaker for Baxter, and receives an honorarium from Stryker NSE.

  • The authors have no other funding, financial relationships, or conflicts of interest to disclose.

Abstract

Objectives/Hypothesis:

Cerebrospinal fluid (CSF) leaks continue to be the most common postoperative complication in expanded endonasal skull base procedures. Currently, a multilayer closure using a vascularized nasoseptal flap is most commonly performed for large ventral skull base defects in an effort to avoid postoperative CSF leaks. We correlated nasoseptal flap enhancement with postoperative CSF leak rates in a group of skull base reconstruction patients. The nasoseptal flap enhancement was determined by immediate postoperative gadolinium-enhanced magnetic resonance imaging (MRI), which allowed for imaging of the flap's vascular pedicle. Our aim was to identify whether nasoseptal flap enhancement contributed to reduction of postoperative CSF leak rates.

Study Design:

Retrospective cohort study.

Methods:

We reviewed 19 patients who underwent expanded endoscopic resections of skull base lesions of advanced complexity. We calculated the incidence of CSF leaks and measured the presence of nasoseptal flap enhancement.

Results:

Of the 19 patients with immediate postoperative MRIs, three developed postoperative CSF leaks. All three CSF leaks were in cases with enhancing vascular pedicles. In contrast, we had three patients without evidence of flap enhancement, none of whom developed a postoperative CSF leak (Fisher exact test, P = 1.0). CSF leak was associated with posterior fossa lesions (P = .25). Nasoseptal flap enhancement was associated with younger age (P = .15).

Conclusions:

This retrospective cohort study demonstrates that although the vascularized pedicled nasoseptal flap is effective for closure of expanded endonasal skull base procedures, our experience found the actual enhancement of the flap itself does not appear to effect postoperative CSF leak rates. Laryngoscope, 2012

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